New research suggests coaching overweight or obese pregnant women to improve their ability to plan and progress toward goals may be vital to helping them lower the amount of fat in their diet.

Maternal diet quality affects prenatal development and long-term child health outcomes. Still, the stress that typically increases during pregnancy – often heightened by concern for fetal health and anxiety over impending parenthood – may derail efforts to focus on healthful eating, previous research has shown.  

In this new study, researchers at The Ohio State University set out to identify the pathway between stress and total fat consumption, with a broader goal to evaluate an intervention designed to improve the diets of pregnant women who are overweight or obese.

Through a series of questionnaires and statistical analysis, the team found that two thinking-related skills – planning and execution of those plans – were weakened in women whose stress was high, and those skill gaps were associated with higher total fat intake.

These two skills are executive functions, a set of multiple thinking processes that enable people to plan, monitor behavior and execute their goals.

“People with a higher stress level tend to have a higher fat intake, too. If stress is high, we’re so stressed out that we’re not thinking about anything – and we don’t care what we eat,” said lead author Mei-Wei Chang, associate professor of nursing at Ohio State.

“That’s why we focused on executive functions as a mediator between stress and diet. And with this baseline data, we have reasons to believe that designing an intervention around executive functions could improve dietary outcomes,” she said. “I would anticipate the results could be similar for nonpregnant women because it’s all about how people behave.”

The study was published recently in the Journal of Pediatrics, Perinatology and Child Health.

The 70 women enrolled in the study had a pre-pregnancy body mass index of between 25 (scores between 25 and 29.9 are categorized as overweight) and 45 (scores of 30 and higher are categorized as obese).

The participants completed questionnaires assessing both overall perceived stress and pregnancy-related stress, as well as executive functions – specifically focusing on metacognition, the ability to plan, and behaviour regulation, the ability to execute those plans. They also completed two 24-hour dietary recalls of their calorie intake and consumption of total fat, added sugar, and fruits and vegetables.

“We were interested in the mediation role of executive functions. The mediator is what makes everything happen,” Chang said. “We wanted to know: If we focus intervention on executive functions, would that carry through to behaviour change in dietary intake?

“Weight loss interventions often involve a prescribed diet or meal plan, and you are told to follow it. But that doesn’t lead to behaviour change in the long term.”

Statistical modelling showed that higher perceived stress was associated with a worsened ability to plan and monitor behaviour, and that pathway was linked to higher total fat intake. Similarly, higher levels of pregnancy-related stress were associated with a lower ability to plan, which in turn was associated with the worsened ability to monitor behaviours related to carrying out the plan – and these factors were linked to higher fat consumption.

These pathways suggested that an intervention designed to lower stress would function as a starting point to improve the diet and enhancing skills through coaching – emphasizing the ability to plan, including being flexible with planning, and behaviour monitoring, particularly when making food choices – would be key to changing eating patterns.

“You need to improve executive functions, and you also need to lower stress,” Chang said. She and colleagues are now analyzing data on the effectiveness of an intervention for the study participants that emphasized stress management and boosting executive function to promote healthy eating.

A specific region of the brain regulates executive functions, and strengths or weaknesses in these skill areas are thought to be affected by various physiological factors. Previous research has found that executive function deficits are more likely to occur in women who are overweight or obese than in women whose weight is average.

“Executive function is not well-studied, and it is not related to intelligence. But people with low executive function cannot make detailed plans and stick to them, and that’s how they get into trouble,” Chang said. “Metacognition and behaviour regulation must go hand in hand – that way you have a much better chance to control your behaviours, and then you will eat better.”

A first study of its kind by Tel Aviv University researchers examined the “secret magic” of medical clowns

According to researchers from Tel Aviv University and the Israel Center for Medical Simulation: “medical clowns not only help the patients, but they also help the parents, the medical team, and the achievement of therapeutic goals. In fact, through various communication skills, clowns enable patients to overcome crises and move towards healing.”

Not just fun and games: a new study tested and categorized the skills of medical clowns found that their importance goes far beyond just creating a good mood for patients. The researchers identified 40 different skills of medical clowns, including establishing an emotional connection and creating a personal relationship with the patient, expressing the patient’s voice about his/her frustrations and difficulties to the medical staff, increasing the patient’s motivation to adhere to the medical treatment, distracting the patient from pain, and creating an atmosphere of games and play. The findings emphasize that the importance of clowns goes far beyond “providing just a good mood” for patients.

The research was conducted under the leadership of Prof. Orit Karnieli-Miller, with Dr. Lior Rosenthal, both from the Department of Medical Education at Tel Aviv University, in collaboration with Ms. Orna Divon-Ophir, Dr. Doron Sagi, Prof. Amitai Ziv and Ms. Liat Pessach-Gelblum from the Israel Center for Medical Simulation (MSR). The study was published in Qualitative Health Research, a leading journal in the field of health.

Prof. Orit Karnieli-Miller CREDITTel Aviv University

The researchers show that medical clowns not only help the patients and their family members, but also the medical team and the achievement of treatment goals. Through use of different communication skills, clowns make it easier for the patient to cooperate with one or another treatment. The medical clowns work in a team with other therapists and know how to intervene and help when an argument or crisis arises, and help overcome it and advance treatment.

Earlier studies showed medical clowns as trained professionals whose goal is to change the hospital environment through humor. Studies conducted throughout the years have shown the clowns’ positive influence on this and in helping patients deal with pain. However, so far, no studies have empirically mapped the skills they use and their therapeutic goals to help understand their “secret magic.” In addition, there was a lack of broad understanding of how clowns can help children, teenagers, and their parents in various challenging situations of distress and difficulty, as well as how they can help patients and medical teams achieve treatment goals. This lack of appreciation of the potential benefits of utilizing the services of a medical clown meant that sometimes patients and medical teams could be reluctant to cooperate with them.

As part of the new study, the team of researchers focused on qualitative, in-depth systematic identification of the skills of medical clowns through observation and analysis of their actions in challenging encounters with adolescents, parents, and medical staff. The team analyzed videotaped sessions of medical clowns in various simulated situations and conducted in-depth interviews with expert medical clowns. The researchers identified forty different skills used by the medical clowns to achieve four therapeutic goals: 1) building a relationship and connecting to the needs and desires of the patients; 2) dealing with emotions and difficulties; 3) increasing the patient’s motivation to adhere to the treatment plan; and 4) increasing the patient’s sense of control and providing encouragement to patients.

The clowns examined in the study were trained and recruited by the “Dream Doctors Project”, a non-profit association that employs medical clowns as part of the paramedical system in Israeli hospitals, and trains them to work within multi-disciplinary teams. The Tel Aviv University researchers collaborated with the Israel Center for Medical Simulation (MSR), which created a simulation-based workshop focused on developing the skills of experienced medical clowns.

Prof. Karnieli-Miller: “from the moment they enter the room, the clowns form a bond with the patients, strengthen them, and give them power and status within the medical system. They do this through an initial connection to the patients’ voice, and even to the patients’ reluctance to implement therapeutic recommendations – an emotional connection that often results in the patient changing their position and cooperating with the medical staff. The medical system is hierarchical, and it is not always easy for patients to navigate. Therefore, one of the skills of medical clowns is to place themselves in the lowest position in the medical setting. By doing so they empower the patients, giving the patients power and control, including the choice of whether to allow the clown to enter the room as well as to dictate the nature of the patient’s role vis-à-vis that of the clown. This provides an increased sense of control and gives the patient courage to face their challenges.”

The researchers emphasize that the clowns are very aware of the emotional difficulty associated with staying in a hospital and dealing with an illness. To deal with these issues the clowns sometimes distract the patient by using props, humor, and imagination. Other skills include the clowns allowing the patient to direct their frustrations towards them, away from the medical staff or parents. Depending on the situation the clowns may also use a comforting touch, soothing music, empathetic listening, or a reinforcing statement to provide an environment where the patient feels comfortable to express their feelings. A patient’s ability to gain legitimacy is important and is strengthened by the clowns. Prof. Karnieli-Miller adds: “Mapping the skills and goals of the medical clowns improves their understanding of their role and may help other health professionals appreciate their work methods and the benefits of incorporating these methods into their own practices when faced with similar challenges.”

Prof. Karnieli-Miller concludes: “This research is important because it allows the clowns to enhance their training program and refine their diverse skills to achieve the various therapeutic goals appropriate for different patients, as well as helping health professionals collaborate with the medical clowns. If professionals in the healthcare field will know how and when to cooperate with the medical clowns, they will be able to help patients overcome challenges, and at the same time they may be more tolerant of the clowns’ ‘disruption’ of the hospital care regimen. This appreciation of the clowns’ contribution will provide the clowns with the time and space to connect with patients and help and encourage patients to become more active participants in their treatment plan. Important goals all health professionals aspire to.”